Geriatric Depression Flashcards
what is the community prevalence rate of late life depression
11.2%
list components of a complete assessment for late life depression
A complete assessment for late-life depression requires:
Reviewing the diagnostic criteria for late-life depression
Reviewing current medications, allergies, and substance use
Reviewing current stresses and life situation
Assessing level of functioning/disability
Considering support system, family situation, and personal strengths
Cognitive testing
Neurological exam and physical exam if applicable
Ordering laboratory investigations to identify any medical problems that could contribute to or mimic depressive symptoms (e.g. - hypothyroidism, anemia)
what population makes up the bulk of the increased risk of completed suicides in older adults with depression
older white males
name a scale that can be used to assess late life depression
Geriatric Depression Scale (GDS)
what is the vascular depression hypothesis
cerebrovascular disease predisposes, precipitates, or perpetuates depressive symptoms in late life
vascular disease is thought to affect FRONTO-STRIATAL circuitry –> resulting in executive dysfunction, depression and cognitive impairment
what is the prevalence of delirium superimposed on dementia
ranges from 22-89% of hospitalized and community populations aged 65+ with dementia
what are the cardinal features of depression, dementia and delirium
dementia–> memory loss
delirium–> inattention and confusion
depression–> sadness, anhedonia
compare the onset of depression, dementia and delirium
dementia–> insidious
delirium–> acute or subacute
depression–> slow
compare the course of depression, dementia and delirium
dementia–> chronic, progressive (but stable over the course of the day)
delirium–> fluctuating, often worse at night
depression–> single or recurrent episodes, can be chronic
compare the duration of depression, dementia and delirium
dementia–> months to years
delirium–> hours to months
depression–> weeks to years
compare the LOC in depression, dementia and delirium
dementia–> normal in early stages
delirium–> impaired, fluctuates
depression–> normal
compare attention in depression, dementia and delirium
dementia–> normal (except in late stages)
delirium–> poor
depression–> may be impaired
compare presence of hallucinations in depression, dementia and delirium
dementia–> often absent
delirium–> fleeting, non-systematizes
depression–> not usually (inly if psychotic depression)
compare EEG findings in depression, dementia and delirium
dementia–> normal or mild diffuse slowing
delirium–> moderate to severe background slowing
depression–> usually normal
how well do ADs work to treat depression in dementia
not well–> guidelines do not suggest routine treatment of depression and anxiety with antidepressants
what types of psychotherapy have strong evidence in late life depression
CBT
problem solving therapy
IPT
list 4 ADs that are relatively safe in the elderly
buproprion
mirtazapine
moclobemide
venlafaxine
*lower anticholinergic effect compared to older ADs
–minimizes delirium risk and cognitive impairment risk
in clinical studies, which ADs have been shown to be the most efficacious in the treatment of late life depression
MAOIs and TCAs
which two TCAs have the lowest anticholinergic burden
nortriptyline
desipramine
*most tolerated of the TCAs
what should be the “first step” in pharmacologic treatment of late life depression
monotherapy with one of the following (or in sequence):
duloxetine
mirtazapine
sertraline
venlafaxine
vortioxetine
citalopram
desvenlafaxine
escitalopram
what should be the “second step” in pharmacologic treatment of late life depression (if multiple first step treatments are not effective or not indicated)
switch to:
nortiptyline
fluoxetine
moclobemide
paroxetine
phenelzine
quetiapine
trazodone
buproprion
or combine with:
ablify
methylphenidate
lithium
what should be the “third step” in pharmacologic treatment of late life depression (if multiple 1st and 2nd step treatments are not effective or not indicated)
switch to amitriptyline or imipramine
or
combine an SSRI or SNRI with buproprion
how does mortality rate compare between older adults that receive ECT for depression vs other treatments
older adults who receive ECT have a LOWER mortality rate compared to other depression treatments (like antidepressants)
what combination of ECT and ADs has evidence for rapidly acting and effective treatment of late life depression
RUL ultrabrief pulse ECT (avg. 7 treatments of ECT) + venlafaxine
very good safety and tolerability when this combination is used
list psychosocial interventions that have evidence for preventing or reducing depressive symptom burden in older adults according to the CCSMH guidelines
- interventions to reduce loneliness in older adults (i.e physical exercise programs)
- “social prescribing”–referral to local nonclinical services often provided by voluntary or community sector
- stepped care approach (including watchful waiting and CBT based bibliotherapy)
- increasing physical activity
- “instilling of hope and positive thinking”
- tai chi/yoga and other mind-body interventions
in which older patients is ECT a first line treatment
older, depressed patients who are at high risk of poor outcomes–> those with suicidal ideation or intent, severe physical illness, or with psychotic features
in which older patients should you consider ECT
treatment of older patients with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate antidepressant trials plus psychotherapy
especially if health is deteriorating due to depression
what psychotherapy may be considered in patients with cognitive impairment and executive dysfunction
problem solving therapy
name two antidepressants that the CCSMH guidelines recommend considering as first line pharmacotherapy for acute episode of MDD in older adults
sertraline or duloxetine
(could also consider citalopram or escitalopram as few drug-drug interactions but this has more risk for QTc prolongation)
*ideally choose a med with lowest risk of anticholinergic side effects and drug-drug interactions as well as being safe in terms of cardiac comorbidity
in which patients might a trial of rTMS be considered
older adults with unipolar depression who have failed to response to at least 1 adequate trial of AD
*not in those who have failed ECT or have seizures
what is first line for treatment of depression in patients with parkinsons disease
SSRIs with SNRIs as alternative
what is first line for treatment of post stroke depression
SSRIs (regardless if stroke is ischemic or hemorrhagic)
–SNRIs or mirtazapine are second line
–consider methylphenidate if APATHY is significant
What is a scale that can be used instead of the geriatric depression scale (GDS) for those people with cognitive impairment
the Cornell Scale for Depression in Dementia
how should geriatric patients with minor depression of less than 4 weeks duration be managed
supportive psychotherapy or psychosocial interventions
when should pharmacotherapy be considered in geriatric patients with depression
after 4 weeks of symptoms after psychosocial interventions have been initiated
can also consider evidence based psychotherapy at this time
how should mild or moderate late life depression be treated
pharmacotherapy, psychotherapy, or both
how should severe late life depression be treated
combo of antidepressants and concurrent psychotherapy
when should ECT be considered in late life depression
those with severe unipolar depression who have previously had a good response to ECT and/or failed to respond to 1 or more adequate trials of antidepressant trials plus psychotherapy
especially if health deteriorating rapidly due to depression
in which patients is ECT a first line treatment
older, depressed patients who are at high risk of poor outcomes–> suicidal, severe physical illness, psychotic features
how should an older patient with psychotic depression be managed
clinician should use clinical judgment deciding whether to try combo AD and AP first (now have placebo controlled trials reporting this is safe and effective treatment for psychotic depression)
ECT should be considered after 4-8 weeks of combo therapy fails, if poorly tolerated or if patient develops severe health consequences
which patients should be referred to psychiatry services in late life
psychotic depression
bipolar disorder
depression with SI
those with depression with comorbid substance use d/o, severe MDD and depression with comorbid dementia may also benefit from referral
is broad use of pharmacogenetic testing recommended in older adults
no
those with recurrent severe side effects to multiple ADs may benefit from testing to see if CYP450 metabolism is contributing
how well to older adults respond to AD therapy compared to young adults
similar
should ADs be used the same in those with multiple comorbidities and serious illnesses
yes–> should be used when indictaed
have similar efficacy rates in unwell elderly as they do in well elderly
AEs in patients with multiple medical comorbidities can be minimized by careful selection of drugs that are not likely to worsen or complicate patient specific medical problems
list side effects of TCAs that are particularly worrisome for the elderly
postural hypotension/falls
cardiac conduction defects
anticholinergic effects (delirium, dry mouth, urinary retention, constipation)
in the elderly, how should you monitor for hyponatremia when starting an AD
screen patient for history of hypoNa before starting the med
serum sodium should be done within 2-4 weeks of initiating SSRI/SNRIs
list 3 types of ADs that have lower risk of hyponatremia
TCAs
bupropion
mirtazapine
how should ADs be titrated in older adults
start at HALF the recommended dose for younger adults –> aim to reach an average dose within ONE MONTH if med is well tolerated at weekly reassessments
why is fluoxetine not recommended for older adults
long half lfie
why is paroxetine not recommended for older adults
higher anticholinergic risk
how long should an older adult be treated with pharmacotherapy after successful remission of their first episode of depression
at least one year (and up to 2 years) with full therapeutic dose
which older adult patients should continue AD maintenance treatment indefinitely (unless there is a contraindication)
those who have had 2 or more episodes
those who have had particularly severe or difficult to treat episodes or required ECT
what is the first line for treatment of bipolar disorder in the elderly
lithium
